February 8, 2018
Earn and Keep Your Market Share Through Reimbursement Support
Market adoption of new medical devices in the United States is largely dependent on the availability of an applicable CPT® code for use in reporting the services provided. Additionally, the existence of positive insurance medical policies outlining coverage for a particular product or service are necessary. The absence of one of these components will greatly affect your market share.
Unfortunately, insurance medical policy determinations and CPT® codes are often implemented at a slower pace than the development of new technologies. The absence of an applicable CPT® code leaves physician and facility providers without a method to report their services to insurance companies for payment. To further complicate matters, the existence of a CPT® code does not automatically ensure positive insurance medical policy determinations will be available from the many national and local commercial and government payers in the United States. Without insurance coverage providers and patients alike are unlikely to acquire the technology
It is imperative that medical device manufacturers have an understanding of the unique challenges their customers will face during the market adoption process and implement a strategy to provide ongoing support for customers and their patients.
Three common Reimbursement Support Services are:
1. Payer and Market Research
Payer and market research provides an understanding of insurance coverage and the reimbursement rates available to the providers and facilities utilizing the device. This information enables the development of a reimbursement strategy to address any CPT® coding and insurance coverage issues. A reimbursement strategy may include the development of new clinical data to support petitions for positive insurance medical policies where they are currently negative.
2. Development of Coding and Reimbursement Guidance Documents
The development of coding and reimbursement guidance documents delivers coding and reimbursement support for delivery to provider and facility customers.
3. Provider and Patient Support Hotlines
The establishment of dedicated company specific coding, coverage and reimbursement hotlines helps providers, sales representatives and patients navigate their way through an evolving insurance market. Coding support hotlines allow providers and sales representatives a centralized location to obtain accurate, consistent coding and reimbursement assistance via an unbiased third party. The coverage assistance hotlines provide one on one patient advocacy support throughout the insurance pre-authorization and appeals processes. This patient advocacy support can allow for access to a new technology even where a negative insurance medical policy exists.
Timing is everything. While reimbursement can be considered both pre and post market, the earlier the reimbursement landscape is considered, the more opportunity there is to address any hurdles to market. For example, having an understanding of the current insurance coverage climate at product conception will allow for potential inclusion of any necessary study endpoints to address any gaps in data needed to support positive payer coverage decisions. In addition, understanding the reimbursement landscape and assisting clinical sites with reimbursement challenges can help to speed recruitment in post-approval clinical trials.
The reimbursement landscape is always evolving which means your reimbursement strategy needs to evolve as well. A knowledgeable reimbursement expert can assist throughout all the phases of the market adoption process. Reimbursement will require hands on support and constant observation in order to stay ahead of the market changes. MileStone’s experienced coding and reimbursement experts are Certified Professional Coders who are trained in all specialty areas of AMA CPT®. The team possesses years of experience in navigating the reimbursement pathway from product conception through post market adoption. Contact our support team for more information on how we can support your reimbursement needs.
“The time to look at your reimbursement landscape is now” Jennifer Varela
A Patient Case Study
A spine surgeon was struggling to obtain approval from the patient’s insurance company for the use of a new spine device. This physician needed an effective way to get the insurance company to consider this new technology for approval in order to provide their patient with the preferred treatment option.
This patient’s case was referred to MileStone Research Organization’s (a Factory CRO Company) manufacturer specific Coverage Assistance Line for assistance with the insurance denial citing, “experimental/investigational” status for the new spine device. MileStone’s patient advocate obtained the appropriate patient consent and reviewed the details of the case. The patient advocate then provided the patient with support materials and individualized step by step instruction on how to complete and submit their appeal to their insurance company. Ultimately, an external reviewer examined all of the clinical and supporting literature submitted by the patient with the help of the patient advocate. After careful consideration the external reviewer determined the procedure was medically necessary and overturned the insurance company’s initial denial enabling immediate patient access to the much needed procedure.